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Der Chirurg

, Volume 90, Issue 4, pp 270–278 | Cite as

Qualitätsindikatoren bei der Therapie der Analfisteln

  • O. SchwandnerEmail author
Leitthema
  • 232 Downloads

Zusammenfassung

Analfisteln stellen ein häufiges proktologisches Krankheitsbild dar und können mit einem Perianalabszess assoziiert auftreten. Die Ätiologie wird durch eine kryptoglanduläre Infektion im Intersphinktärraum bestimmt. Die Therapie der Analfistel ist chirurgisch. Oberstes Ziel der Fistelchirurgie bleibt die Heilung, wobei der „Erfolg“ von verschiedenen Faktoren abhängt, u. a. Erfahrung des Chirurgen, Art der Fistel, Beteiligung des Schließmuskels, Art des Operationsverfahrens sowie patientenassoziierte Faktoren. Bei der chirurgischen Therapie der komplexen Analfistel stehen verschiedene operative Verfahren zur Verfügung: die Fistelspaltung mit Schließmuskelrekonstruktion, plastische Verfahren (z. B. Mukosa-Flap, Muskel-Mukosa-Flap) sowie sog. „sphinktererhaltende“ Verfahren wie LIFT („ligation of intersphincteric fistula tract“), VAAFT („video-assisted anal fistula treatment“), die Verwendung eines Plugs, von Kollagen oder Fibrinkleber als auch Laserverfahren oder der Clip. Auf der Suche nach geeigneten Qualitätsindikatoren in der analen Fistelchirurgie besteht ein Spannungsfeld zwischen Heilung einerseits und dem Kontinenzerhalt andererseits. Identifiziert man potenzielle Qualitätsindikatoren, sind sowohl die Grundsätze der Analfistelchirurgie zu beachten als auch die entsprechende Patientenselektion bzw. Verfahrenswahl von entscheidender Bedeutung, um hohe Heilungsraten zu erreichen, ohne beträchtliche Kontinenzstörungen oder hohe Revisionsraten wegen eines Abszesses oder Rezidivs zu induzieren. Vor dem Hintergrund der vorliegenden Literatur und Leitlinien bestehen in der Bewertung von Qualitätsindikatoren erhebliche Unterschiede hinsichtlich Patientenselektion, Ätiologie der Analfistel, Dauer der Nachbeobachtung und Heterogenität der Therapieregime, die eine definitive Bewertung erschweren, welche chirurgische Therapie die beste bei der komplexen Analfistel darstellt.

Schlüsselwörter

Fistelspaltung Qualitätsindikator Heilung Rezidiv Kontinenz 

Quality indicators in the treatment of anal fistulas

Abstract

Anal fistulas are a common anorectal disease and are frequently associated with a perianal abscess. The etiology is based on a cryptoglandular infection in the intersphincteric space. Surgery remains the only definitive therapy. The primary goal of definitive fistula surgery is healing; however, success of fistula surgery is influenced by a variety of factors including the surgeon’s experience, type of fistula, involvement of sphincter muscles, type of surgical procedure and patient-related factors. For the surgical treatment of a complex anal fistula, a variety of operative procedures have been described including fistulectomy with sphincterotomy, different flap procedures (e.g. mucosal flap and advancement flap) and finally so-called sphincter-preserving techniques, such as LIFT (ligation of intersphincteric fistula tract), VAAFT (video-assisted anal fistula treatment), the use of plugs of collagen or fibrin glue sealants as well as laser procedures or the clip. In the search for suitable quality indicators in anal fistula surgery there is a conflict between healing and preservation of continence. If potential quality indicators are identified the principles of anal fistula surgery must be adhered to and the appropriate selection of patients and procedures is of crucial importance to achieve high healing rates without compromising continence or inducing surgical revision due to abscesses or recurrence. Based on the available literature and guidelines, in the assessment of quality indicators considerable differences exist with respect to patient selection, etiology of anal fistulas and length of follow-up. Heterogeneity of treatment protocols lead to difficulties in a definitive assessment of which surgical treatment is the best option for complex anal fistulas.

Keywords

Fistulectomy Quality indicator Healing Recurrence Continence 

Notes

Einhaltung ethischer Richtlinien

Interessenkonflikt

O. Schwandner: Honorare für Vortragstätigkeit 2018 (Fa. Takeda, Berlin, Deutschland).

Dieser Beitrag beinhaltet keine vom Autor durchgeführten Studien an Menschen oder Tieren.

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Copyright information

© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2019

Authors and Affiliations

  1. 1.Abteilung für ProktologieKrankenhaus Barmherzige Brüder RegensburgRegensburgDeutschland

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